Property: the Hitchner Management Agent

ASSET INFORMATION

(Include all assets held and income derived from the asset. Include all assets held by all household members including minor children)

Do YOU or ANYONE in your household hold:

Checking or Savings Account?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

Certificates of Deposits, Money Market accounts or Treasury Bills?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

Stocks, Bonds or Securities?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

Trust Funds?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

IRA, 401(k), Keogh or other retirement accounts?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

Personal Property held as an investment?



Yes



No

(This includes paintings, coin or stamp collections, artwork, collector or show cars and antiques. This does not include your personal belongings such as our car, furniture or clothing)

Household Member

Description of Property

Value

Income

per

per

Whole Life Insurance Policy? (This does not mean Term Life Insurance)



Yes



No

Household Member

Financial Institution

Value

Income

per

per

A Safe deposit box?



Yes



No

Household Member

Financial Institution

Value

Income

per

per

Real Estate, rental property, land contracts/contract for deeds or other real estate holdings?



Yes



No

(This includes your personal residence, mobile homes, vacant land, farms, vacation homes or commercial property)

Household Member

Financial Institution

Value

Income

per

per

Have your or has anyone in your household disposed of any business or asset for LESS than fair market value during the past two (2) years?



Yes



No

Household Member

Value of Disposed of Asset

Date of Disposition